General Medical and Gynecological Examinations (ICD-9-CM V70.0, V72.31, V72.32) (Excluding Contraceptive and Procreative Codes)
ICD-9-CM V72.31 is a billable medical code that can be used to indicate a diagnosis on a reimbursement claim, however, V72.31 should only be used for claims with a date of service on or before September 30, 2015. For claims with a date of service on or after October 1, 2015, use an equivalent ICD-10-CM code (or codes).
The appropriate medical E/M office visit code (99201-99215) may be reported with modifier 25 in addition to the gynecological examination (G0101). If the reported service (s) do not meet the component requirements of the codes billed the services should not be billed.
The below billing guidelines are provided to educate providers on correct billing. When a physician performs a systemic physical examination as part of an annual gynecological examination and provides an unrelated, separately identifiable E/M on the same day both services may be billed.
Z01.419411, Encounter for gynecological examination (general) (routine) with abnormal findings, or Z01. 419, Encounter for gynecological examination (general) (routine) without abnormal findings, may be used as the ICD-10-CM diagnosis code for the annual exam performed by an obstetrician–gynecologist.
Z01.419Encounter for gynecological examination (general) (routine) without abnormal findings. Z01. 419 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM Z01.
V70. 0 Routine medical exam - ICD-9-CM Vol.
V67.99 for Unspecified follow-up examination is a medical classification as listed by WHO under the range -PERSONS ENCOUNTERING HEALTH SERVICES IN OTHER CIRCUMSTANCES (V60-V69).
Well Women Exam CPT Code CPT G0101 may be used to report Well Woman Exam. The description of the CPT code for Well woman is as follows: “Cervical or vaginal cancer screening; pelvic and clinical breast exam.”
Vaginal Pap test (Z12. 72)
The Annual Routine Physical Exam can be documented using codes 99385-99387 for new patients and codes 99395-99397 for established patients.
AWV Coding. The two CPT codes used to report AWV services are: G0438 initial visit. G0439 subsequent visit.
Physical Exam CPT Codes For New Patients CPT 99384: New patient annual preventive exam (12-17 years). CPT 99385: New patient annual preventive exam (18-39 years). CPT 99386: New patient annual preventive exam (40-64 years). CPT 99387: New patient annual preventive exam (65 years and older).
ICD-10 code Z09 for Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
ICD-9-CM is the official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States. The ICD-9 was used to code and classify mortality data from death certificates until 1999, when use of ICD-10 for mortality coding started.
CMS will continue to maintain the ICD-9 code website with the posted files. These are the codes providers (physicians, hospitals, etc.) and suppliers must use when submitting claims to Medicare for payment.